Patient Safety Tip of the Week


May 8, 2012

Importance of Non-Technical Skills in Healthcare



Non-technical skills are as important or even more important than technical skills in a variety of fields of healthcare, just as they are in aviation, the military, or a variety of high-risk industries. Especially in areas where events are rapidly evolving, skills such as situational awareness and ability to communicate and work in teams are critically important. So it should be no surprise that these non-technical skills have been studied most often in the OR and ER.


In our March 2012 What’s New in the Patient Safety World column “Human Factors and Operating Room Safety” we noted an article on surgeon’s non-technical skills (Yule 2012) which provides excellent insight into key skills such as situational awareness, decision-making, leadership, communication and teamwork.


So what do we mean by non-technical skills? These are the more cognitive and social skills that are key elements in fostering good teamwork and collaboration and include some of the following:

·        Leadership

·        Communication

·        Situational Awareness

·        Surveillance of the Environment

·        Anticipation

·        Task Distribution

·        Mutual Performance Monitoring

·        Maintaining Focus

·        Decision Making

·        Conflict Resolution

·        Stress Management

·        Fatigue Management

·        Gathering Information

·        Understanding Information

·        Developing Shared Mental Models

·        Listening

·        Appropriate Assertiveness

·        Feedback


Non-technical skills become even more important in teams that come together on a temporary basis (Flin 2004). Those authors point out that, unlike military teams that often train together and work together as a unit for long periods, pilots in commercial aviation often come together with other members of the flight crew on a more temporary basis. The aviation industry has long recognized that problems in non-technical skills, rather than knowledge or flying ability, are significant factors contributing to crashes. They highlight the similarities between aviation and areas in healthcare such as the OR, ICU, and ER and stress how the principles used in crew resource management (CRM) can be applied equally to medicine. They describe how systems were developed to measure non-technical skills in anesthesia (ANTS or the Anesthetists Non-Technical Skills, CARMa or Crisis Avoidance and Resource Management) modeled on the NOTECHS system that had been established for measuring non-technical skills in pilots. Such systems may be used on either videotapes of real OR cases or used on simulations done with teams.


Most studies on non-technical skills in surgery have come from simulated environments (Hull 2012). They point out that there is a high correlation between technical error and teamwork failure.


Two articles in the May 2012 issue of the Annals of Emergency Medicine identify the importance of non-technical skills in emergency department physicians.


Emergency physicians probably have to deal with more interruptions and do more multitasking than physicians in other venues (Flowerdew 2012a). They have to deal with multiple patients simultaneously, some of whom have not even yet arrived at the emergency department. So anticipation, situational awareness, and workload management are crucial non-technical skills for an effective emergency physician. Similarly, communication skills during handoffs are extremely important. In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” we focused on the unique context of handoffs in the ED and discussed the ABC of handover” tool for ED handoffs (Farhan 2012). Rather than focusing on just the transfer of information and responsibility for single patients, they focus on the transfer of responsibility of a whole department, the ED, at change of shift. That includes knowledge of all the patients in the ED, prioritization of risks, pending tests and other issues, patient flow and waiting time issues, staffing patterns, equipment issues, planned patient dispositions (admissions, transfers, discharges), and even events taking place in the community that might impact the ED, and sometimes teaching responsibilities.


In the second article by the same group (Flowerdew 2012b) a tool for assessing non-technical skills of emergency physicians was developed and validated. A copy of that tool is available in the article.


The importance of non-technical skills has also been studied for cardiac arrest teams (Anderson 2010).  The authors identified some barriers to good team function that were based in non-technical skills. Such barriers included inexperienced leadership, task overload, and hierarchical structure. They recommended training should include structured communication, use of cognitive aids, mutual performance monitoring, and avoidance of task overload.


Assertiveness is often a double-edged sword in team situations. Dominating a team can become dangerous but appropriate assertiveness is important. Communication obviously takes place between and among numerous individuals in settings such as the OR. Not being afraid to buck the authority gradient or hierarchy is critical and assertive communication is a key component of good teamwork. One example of escalating assertive communication is the CUSS tool (Yule 2012):

    C   “I’m concerned and need clarification”

    U   “I am uncomfortable and don’t understand”

    S    “I’m seriously worried here”

    S    “Stop”



Attempts to improve non-technical skills via simulation have had mixed results. Anesthesiology residents (Yee 2005) participated in 3 simulated cases and were videotaped and provided feedback. After the first simulation and feedback there was significant improvement in non-technical skills. But there was no further improvement after subsequent simulated cases. However, a similar trial in practicing anesthesiologists (Morgan 2011) was not successful in improving non-technical skills.


Programs such as the TeamSTEPPS™  training program (see our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™” and our March 2009 What’s New in the Patient Safety World column “Surgical Team Training”) are very useful at developing non-technical skills that are crucial to good teamwork.


Formal CRM training programs are also good ways to develop non-technical skills. Most studies looking at CRM training have looked only at short-term outcomes. But our January 2010 What’s New in the Patient Safety World column “Crew Resource Management Training Produces Sustained Results” highlighted a study (Sax et al 2009) that demonstrated improved outcomes that have been sustained over the long run. Outcomes included increased use of preoperative checklists, increased self reporting, more reporting of near misses and environmental conditions, and several measures indicative of a culture of safety.



Many of you have heard the adage “Hire for attitude…Train for Skills”. That, of course, means that having in your organization people with good non-technical skills may be more important that having those who have good technical skills but lack the other important traits we have discussed in today’s column. But, fortunately, there is hope that even though some of those non-technical skills are innate there may be opportunities to improve them through identification, feedback and training.






Yule S, Paterson-Brown S. Surgeons’ Non-technical Skills. Surgical Clinics of North America 2012; 92(1): 37-50



Flin R, Maran N. Identifying and training non-technical skills for teams in acute medicine. Qual Saf Health Care 2004; 13(Suppl 1): i80-i84



Hull L, Arora S, Aggarwal R et al. The Impact of Nontechnical Skills on Technical Performance in Surgery: A Systematic Review. J Am Coll Surg 2012; 214(2): 214-230



Flowerdew F, Brown R, Vincent C, Woloshynowych M. Identifying Nontechnical Skills Associated With Safety in the Emergency Department: A Scoping Review of the Literature. Ann Emerg Med 2012; 59(5): 386-394



Farhan M, Brown R, Woloshynowych M, Vincent C. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J 2012; Published Online First: 3 January 2012



Flowerdew F, Brown R, Vincent C, Woloshynowych M. Development and Validation of a Tool to Assess Emergency Physicians' Nontechnical Skills. Ann Emerg Med 2012; 59(5): 376-385



Andersen PO, Jensen MK, Lippert A, Østergaard D. Identifying non-technical skills and barriers for improvement of teamwork in cardiac arrest teams. Resuscitation 2010; 81(6): 695-702



Yee B, Naik VN,  Joo HS, et al. Nontechnical Skills in Anesthesia Crisis Management with Repeated Exposure to Simulation-based Education. Anesthesiology 2005; 103(2): 241-248



Morgan, Pamela J. MD, FRCPC; Kurrek, Matt M. MD, FRCPC; Bertram, Susan MD, FRCPC; LeBlanc, Vicki PhD; Przybyszewski, Teresa RRT

Nontechnical Skills Assessment After Simulation-Based Continuing Medical Education

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare:

October 2011 - Volume 6 - Issue 5 - pp 255-259



Sax HC, Browne P, Mayewski RJ, et al. Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? Arch Surg. 2009; 144(12): 1133-1137

















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